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摘要：
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摘要：目的 探讨肝硬化腹水患者的临床特征及顽固性腹水患者预后的影响因素。方
法 选取2015年1月至2017年12月于福建医科大学孟超肝胆医院就诊的456例肝硬化腹水
患者进行回顾性研究。根据腹水程度分为1级腹水组（143例）、2级腹水组（191例）
和3级腹水组（122例），比较3组患者疗效、白蛋白（albumin，ALB）水平、血清腹水白蛋白梯度（sero-ascites albumin gradient，SAAG）及Child-Pugh分级情况。将
顽固性腹水患者（64例）根据生存状态分为存活组（32例）及病死组（29例），采用
Cox回归模型分析顽固性腹水患者预后的影响因素。采用Log-rank法分析各危险因素
对患者生存率的影响。结果 1级腹水组、2级腹水组和3级腹水组患者治疗显效率分别
为80.4%（115/143）、63.9%（122/191）、41.0%（50/122），差异有统计学意义
（χ2
= 44.016，P ＜ 0.001），1级腹水组患者显效率显著高于2级腹水组和3级腹水组
（χ
2
= 10.863，P = 0.001；χ
2
= 43.576，P ＜ 0.001），2级腹水组患者显效率显著高于
3级腹水组（χ
2
= 15.758，P ＜ 0.001）。1级腹水组、2级腹水组和3级腹水组患者ChildPugh C级患者比例（17.5% vs 41.4% vs 53.3%；χ
2
= 38.770，P ＜ 0.001）、血清ALB [（27.27 ±
4.37）g/L vs（26.61 ± 2.85）g/L vs（26.22 ± 2.90）g/L；F = 3.266，P = 0.039]、腹水ALB
[（14.48 ± 4.32）g/L vs（14.11 ± 1.99）g/L vs（13.48 ± 2.54）g/L；F = 3.653，P = 0.027]
及SAAG [（13.86 ± 1.99）g/L vs（14.26 ± 3.40）g/L vs（14.87 ± 2.41）g/L；F = 5.558，
P = 0.004] 差异均有统计学意义。Spearman相关性分析表明腹水级别与Child-Pugh分级
呈正相关（rs = 0.442，P ＜ 0.001），与SAAG无相关性（rs = 0.241，P ＜ 0.001）。
顽固性腹水患者中存活组和病死组患者年龄（中位数：47岁 vs 56岁；U = 233.5，P ＜
0.001）、腹水量（中位数：12.6 cm vs 15.6 cm；U = 124.5，P ＜ 0.001）、肝性脑病
（6例 vs 17例；χ
2
= 8.669，P = 0.003）、食管胃底静脉曲张破裂出血（5例 vs 19例；
χ
2
= 13.847，P ＜ 0.001）、自发性腹膜炎（6例 vs 23例；χ
2
= 20.01，P ＜ 0.001）、
血清ALB（中位数：27 g/L vs 23 g/L；U = 689.5，P = 0.001）、肌酐 [（82.77 ±
17.49）mmol/L vs（96.36 ± 18.32）mmol/L；t = -2.957，P = 0.004]、凝血酶原时间
（中位数：16.8 s vs 18.9；U = 134.5，P ＜ 0.001）、血钠（中位数：129 mmol/L vs
125 mmol/L；U = 716，P ＜ 0.001）、血钾（中位数：3.6 mmol/L vs 3.4 mmol/L；U =
627.5，P = 0.018）及Child-Pugh分级（B级/C级：28例/4例 vs 3例/26例；χ
2
= 33.213，
P ＜ 0.001）差异有统计学意义。多因素Cox回归分析表明血钠＞ 128 mmol/L（HR =
0.697，95% CI：0.548～0.885，P = 0.003）、自发性腹膜炎（HR = 5.246，95% CI：
1.246～22.091，P = 0.024）、Child-Pugh C级（HR = 5.129，95% CI：1.012～25.985，
P = 0.048）、肝性脑病（HR = 4.756，95% CI：1.126～20.083，P = 0.034）和食管胃
底静脉曲张破裂出血（HR = 3.234，95% CI：1.100～9.509，P = 0.033）是顽固性腹水
预后的独立影响因素，其中血钠＞ 128 mmol/L为保护性因素。血钠≤ 128 mmol/L患
者3年存活率为25.9%，血钠＞ 128 mmol/L患者3年存活率为70.6%，差异有统计学意
义（Log-rank χ
2
= 14.839，P ＜ 0.001）；合并自发性腹膜炎患者3年存活率为20.7%，
无自发性腹膜炎患者3年存活率为81.3%，差异有统计学意义（Log-rank χ
2
= 21.272，P ＜
0.001）；Child-Pugh C级患者3年存活率为13.3%，Child-Pugh B级患者3年存活率为
90.3%，差异有统计学意义（Log-rank χ
2
= 40.736，P ＜ 0.001）；合并肝性脑病患者
3年存活率为26.1%，无肝性脑病患者3年存活率为65.8%，差异有统计学意义（Logrank χ2
= 10.561，P = 0.001）；合并食管胃底静脉曲张破裂出血患者3年存活率为
20.8%，无食管胃底静脉曲张破裂出血患者3年存活率为73.0%，差异有统计学意义
（Log-rank χ
2
= 22.224，P ＜ 0.001）。结论 肝硬化患者随腹水量增多，Child-Pugh分级
升高，肝脏储备功能下降、疗效越差、SAAG越高。低钠血症、肝性脑病、Child-Pugh
C级、食管胃底静脉曲张破裂出血和自发性腹膜炎是顽固性腹水预后的独立影响因素。
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Abstract: Objective To investigate the clinical characteristics of patients with cirrhotic ascites
and prognostic influencing factors of refractory ascites. Methods A total of 456 patients with
cirrhotic ascites in Mengchao Hepatobiliary Hospital of Fujian Medical University from
January 2015 to December 2017 were selected. The patients were divided into grade 1 ascites
group (143 cases), grade 2 ascites group (191 cases) and grade 3 ascites group (122 cases)
according to the degree of ascites. The curative effect, albumin (ALB) level, serum ascites
albumin gradient (SAAG) and Child-Pugh grade of patients in three groups were compared.
Patients with refractory ascites (61 cases) were divided into survival group (32 cases) and
death group (29 cases), Cox regression model was used to analyze the prognostic influencing
factors. Log-rank method was used to analyze the effect of various risk factors on survival
rate of the patients. Results The effective rates of patients in three groups were 80.4%
(115/143), 63.9% (122/191) and 41.0% (50/122), respectively, the difference was statistically
significant (χ
2
= 44.016, P ＜ 0.001), the effective rate of patients in grade 1 ascites group was
significantly higher than that in grade 2 ascites group and grade 3 ascites group (χ
2
= 10.863,
P = 0.001; χ
2
= 43.576, P ＜ 0.001), the effective rate of patients in grade 2 ascites group was
significantly higher than that in grade 3 ascites group (χ
2
= 15.758, P ＜ 0.001). The ratio of
Child-Pugh C grade (17.5% vs 41.4% vs 53.3%; χ
2
= 38.770, P ＜ 0.001), serum ALB [(27.27 ±
4.37) g/L vs (26.61 ± 2.85) g/L vs (26.22 ± 2.90) g/L; F = 3.266, P = 0.039], ascites ALB [(14.48 ±
4.32) g/L vs (14.11 ± 1.99) g/L vs (13.48 ± 2.54) g/L; F = 3.653, P = 0.027] and SAAG [(13.86 ± 1.99) g/L
vs (14.26 ± 3.40) g/L vs (14.87 ± 2.41) g/L; F = 5.558, P = 0.004] of patients in three
groups were statistically significant. Spearman correlation analysis indicated that the ascites
grade was positively associated with Child-Pugh grade (rs = 0.442, P ＜ 0.001) and had no
correlation with SAAG (rs = 0.241, P ＜ 0.001). Age (median: 47 years old vs 56 years old;
U = 233.5, P ＜ 0.001), ascites quantity (median: 12.6 cm vs 15.6 cm; U = 124.5, P ＜ 0.001),
hepatic encephalopathy (6 cases vs 17 cases; χ
2
= 8.669, P = 0.003), esophageal and gastric
varices rupture and bleed (5 cases vs 19 cases; χ
2
= 13.847, P ＜ 0.001), spontaneous
peritonitis (6 cases vs 23 cases; χ
2
= 20.01, P ＜ 0.001), serum ALB (median: 27 g/L vs 23 g/L; U =
689.5, P = 0.001), creatinine [(82.77 ± 17.49) mmol/L vs (96.36 ± 18.32) mmol/L; t = -2.957,
P = 0.004], prothrombin time (median: 16.8 s vs 18.9; U = 134.5, P ＜ 0.001), blood sodium
(median: 129 mmol/L vs 125 mmol/L; U = 716, P ＜ 0.001), blood potassium (median:
3.6 mmol/L vs 3.4 mmol/L; U = 627.5, P = 0.018) and Child-Pugh grade (grade B /
grade C: 28 cases / 4 cases vs 3 cases / 26 cases; χ
2
= 33.213, P ＜ 0.001) of patients with
refractory ascites in survival group and death group were statistically significant. Multivariate
Cox regression analysis indicated that blood sodium ＞ 128 mmol/L (HR = 0.697, 95% CI:
0.548～0.885, P = 0.003), spontaneous peritonitis (HR = 5.246, 95% CI: 1.246～22.091,
P = 0.024), Child-Pugh C grade (HR = 5.129, 95% CI: 1.012～25.985, P = 0.048), hepatic
encephalopathy (HR = 4.756, 95% CI: 1.126～20.083, P = 0.034) and esophageal and gastric
varices rupture and bleed (HR = 3.234, 95% CI: 1.100～9.509, P = 0.033) were independent
influencing factors affecting the prognosis of patients with refractory ascites, among them, blood
sodium ＞ 128 mmol/L was a protective factor. The 3-year survival rate of refractory ascites
patients with blood sodium ≤ 128 mmol/L and blood sodium ＞ 128 mmol/L were 25.9% and
70.6%, respectively, the difference was statistically significant (Log-rank χ
2
= 14.839, P ＜ 0.001).
The 3-year survival rate of refractory ascites patients with and without spontaneous peritonitis
were 20.7% and 81.3%, respectively, the difference was statistically significant (Log-rank χ
2
=
21.272. P ＜ 0.001). The 3-year survival rate of refractory ascites patients with Child-Pugh grade
C and grade B were 13.3% and 90.3%, respectively, the difference was statistically significant
(Log-rank χ
2
= 40.736, P ＜ 0.001). The 3-year survival rate of refractory ascites patients with
and without hepatic encephalopathy were 26.1% and 65.8%, respectively, the difference was
statistically significant (Log-rank χ
2
= 10.561, P = 0.001). The 3-year survival rate of refractory
ascites patients with and without esophageal and gastric varices rupture and bleed were 20.8%
and 73.0%, respectively, the difference was statistically significant (Log-rank χ2
=
22.224, P ＜ 0.001). Conclusions With the increase of ascites in patients with liver cirrhosis,
Child-Pugh grade showed an increasing trend, liver reserve function gradually decreased, the
efficacy was worse and SAAG increased. Hyponatremia, hepatic encephalopathy, and ChildPugh grade C, esophageal and gastric varices rupture and bleed and spontaneous peritonitis were
independent factors affecting the prognosis of patients with refractory ascites.
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